Medical record forming and storing apparatus and medical record and method related to same

ABSTRACT

A medical record processor and method include a voice processor for receiving unprompted and unstructured free dictation, for processing the dictation, and for generating voice data comprising a plurality of terms therefrom. A key term comparator identifies a key medical term in the generated voice data by comparing each term in the generated voice data with a plurality of key medical terms. The identified key medical terms are separated from non-key medical terms in the generated voice data, and a non-key medical term is eliminated from the generated voice data. The identified key medical term is matched with a patient condition, and additional data are extracted from a knowledge database on the patient condition. A draft medical record is generated that includes the identified key medical term and the additional data.

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application is a continuation of and incorporates byreference co-pending application Ser. No. 09/133,548, filed Aug. 13,1998, commonly owned with the present application.

FIELD OF THE INVENTION

[0002] This invention is related to the medical office automationindustry and more particularly to the field of forming medical recordsin the medical industry.

BACKGROUND OF THE INVENTION

[0003] Over the years, various office automation equipment has beendeveloped for providing offices with automatic systems for dictation,transcription, word processing, financial analysis, and other officefunctions which could be automated. This office automation equipmentgenerally applied to all types of offices including sales, financial,legal, insurance, research, medical and various service or otherbusiness offices. Each type of office or general field of the office,however, often has their own constraints and problems for officeautomation equipment. The medical field, for example, has attempted toautomate the diagnosis of a patient's illness based upon a patient'ssymptoms and then often recommended a corresponding patient treatment.Examples of such systems can be seen in U.S. Pat. No. 4,733,354 byPotter et al. titled “Method And Apparatus For Automated MedicalDiagnosis Using Decision Tree Analysis,” U.S. Pat. No. 4,839,822 byDormond et al. titled “Computer System And Method For SuggestingTreatments For Physical Trauma,” U.S. Pat. Nos. 4,872,122 and 5,005,143by Atlschuler et al. and each titled “Interactive Statistical System AndMethod For Predicting Expert Decisions,” and U.S. Pat. No. 5,692,220 byDiamond et al. “Decision Support System And Method For DiagnosisConsultation In Laboratory Hematopathology.” Although such systems canhave a role in medical office and hospital automation, such systems areoften limited to a research location, e.g., using a knowledge base whichcorrelates patient symptoms to diagnosis of an illness and/orrecommendations of a treatment, for only selective uses. In other words,the physician or other medical personnel remain the primary patientcontact and interface, and diagnosis and treatment decisions usuallyremain substantially in the hands of the physician.

[0004] Because the physician or other medical personnel, e.g., nurses,nurse assistants, technicians, remain the primary patient contact andprimary decision maker, the physician or other medical personnel arealso primarily responsible for creating the medical record or history ofa patient such as the creating or forming of a progress note ornarrative description during a patient encounter. These medical recordsoften become more and more critical to an office, hospital, or otherorganization, e.g., the medical records representing a complete recordof a patient's health care administered by a physician, other medicalpersonnel, or the facility in general. Accordingly, attempts have beenmade over the years to automate the medical history taking process.Examples of such attempts can be seen in U.S. Pat. No. 4,130,881 byHaessler et al. titled “System And Technique For Automated MedicalHistory Taking,” U.S. Pat. No. 5,146,439 by Jachmann et al. titled“Records Management System Having Dictation/Transcription Capability,”U.S. Pat. No. 5,265,075 by Bergeron et al. titled “Voice ProcessingSystem With Editable Voice Files,” and U.S. Pat. No. 5,327,341 by Whalentitled “Computerized File Maintenance System For Managing MedicalRecords Including Narrative Reports.” Some of these automated medicalrecord forming systems, for example, require that a user enterinformation about a patient into selected fields so that the medicalrecord is formed by question and answer prompts or data entry into whatis essentially a form, e.g., based upon a limited set of predeterminedanswers to a prompted question. Others of these systems merely allowtranscribed files to be accessed again or allow portions of files whichare similar to not need repetition. Such systems, however, providelittle utility for a physician directly and require that the physicianadapt to some style, format, language usage, or other constraints of theautomated system and provide little or no freedom for the physician'sown style. Additionally, such systems often require additional personnelto transcribe, enter and manage the forms and require personnel trainingand learning of the particular format used by the system. Others ofthese automated medical record forming and management systems oftenrecord and transcribe dictation for entry into a computer or data basewhich then can create, update, and manage medical records. Some of thesesystems allow a physician to dictate but require a transcriber toextract pertinent sections from the dictated report for entry into thecomputer in predefined categories. Accordingly, these systems alsorequire additional personnel to transcribe dictation, enter and managethe forms, and to be trained and learn the particular format used by thesystem.

SUMMARY OF THE INVENTION

[0005] In view of the foregoing, the present invention advantageouslyprovides an apparatus and method for forming a medical record which doesnot require a separate transcriptionist for transcribing a dictatedmedical record. The present invention also advantageously provides anapparatus and method for forming a medical record which allows aphysician or other medical personnel to freely dictate medical datarelated to a medical record so that the resulting product will be amedical record in either a selected or predetermined format. The presentinvention additionally advantageously provides an apparatus and methodfor forming a medical record which recognizes free, unprompted, andunstructured speech from a physician or other medical personnel andresponsively translates the speech into a structured medical recordformat which is either selected by the user or predetermined by the useror system. The present invention also additionally provides an apparatusand method for forming a medical record which recognizes key medicalwords or terms in the free, unprompted, and unstructured dictation sothat relationships can be made between the medical terms, other relatedmedical terms, a patient's conditions, and potential treatments tothereby form at least a draft medical record therefrom. The presentinvention further advantageously provides a medical record which isstructured or formed from a relationship between medical terms used by aphysician or other medical personnel and other related medical terms,patient conditions, and potential treatments. The present inventionstill further advantageously provides a medical record which is formedby free, unprompted, and unstructured dictation by a physician or othermedical personnel by recognizing key medical words or terms in thedictation to thereby form a medical record based upon either a selectedor predetermined format.

[0006] More particularly, a medical record forming and storing apparatusis provided which preferably includes voice inputting means, e.g.,preferably provided by a voice recorder, for inputting the unpromptedand unstructured free dictation of at least one medical personnel suchas a physician, voice processing means, e.g., preferably provided by avoice processor, responsive to the voice inputting means for processingthe recorded voice from the voice inputting means and generating voicedata therefrom, and key term recognizing means, e.g., preferablyprovided by a key term recognizer, responsive to the voice processingmeans for recognizing key medical terms freely dictated by the at leastone medical personnel. The apparatus also preferably includes medicalterm matching means, e.g., preferably provided by a medical termmatcher, responsive to the key term recognizing means for matchingmedical terms used by the at least one medical personnel at least withpatient conditions and/or treatments. The medical term matching meanspreferably includes a knowledge database relating patient conditionswith patient treatments of the conditions so that the knowledge baseassists in further describing at least the actual condition and/ortreatment of the patient by adding additional data, e.g., a morecomplete description, to a medical form which is or will be created. Theapparatus can further include medical record creating means, e.g.,preferably provided by a medical record creator, responsive to themedical term matching means for creating an actual patient medicalrecord therefrom.

[0007] As used herein, the term free dictation means the unstructuredand unprompted dictation of the at least one medical personnel, e.g., aphysician. By unstructured and unprompted, it is recognized that words,sentences, and paragraphs have structure which often prompts additionalstructure such as a limited set of predetermined answers to a promptedquestion. Nevertheless, this is not the intent of the meaning ofunstructured and unprompted. Rather, medical personnel such asphysicians are allowed to freely dictate words, terms, sentences,phrases, paragraphs, and other language structure without the necessityof using only selected words, terms, phrases, paragraphs, and otherstructure required by the system into which the physician or othermedical personnel dictates or speaks. In other words, the dictation doesnot have to be within a given format required by the medical recordforming system outside of normal language usage by the speaking orspeech of the medical personnel and is preferably not based upon alimited set of predetermined answers to a prompted question.

[0008] By advantageously using or keying off of key medical terms usedby a physician or other medical personnel such as in free, unprompted,and unstructured dictation, the apparatus and method provide freedom forthe physician to talk, speak, and dictate according to the physician'spersonal preferences, style, language, vocabulary, tone, and otherdesires when forming a medical record. Non-key medical terms or otherunrecognized words, for example, can advantageously be discarded orstored for future reference. The physician, for example, does not haveto fit within the constraints or format requirements of the system whichreceives the dictation and forms the medical record therefrom. Becausethe free dictation is the preferred format and key medical terms arerecognized by the apparatus, additional personnel to transcribe thephysician's dictation are not needed.

[0009] According to one aspect of the present invention, the key termrecognizing means, for example, can include key medical term storingmeans for storing a plurality of key medical terms, comparing meansresponsive to the key medical term storing means for comparing the voicedata with key medical terms within the key medical term storing means,and separating means responsive to the comparing means for separatingthe key medical terms from the non-key medical terms.

[0010] According to another aspect of the present invention, the medicalrecord creating means, for example, can advantageously include draftrecord generating means for generating a draft medical record related tothe at least one medical personnel's dictation for review by the atleast one medical personnel, record revising means responsive to the atleast one medical personnel for revising the draft medical record, andrecord accepting means responsive to the at least one medical personnelfor accepting the draft medical record.

[0011] According to still further aspects of the present invention amedical recording forming and storing apparatus preferably includes avoice input device for inputting dictation of at least one medicalpersonnel, a voice processor responsive to the voice input device forprocessing the inputted voice and generating voice data therefrom, a keyterm recognizer responsive to the voice processor for recognizing keymedical terms dictated by the at least one medical personnel. The keyterm recognizer preferably includes a key medical term database forstoring a plurality of key medical terms therein. The apparatus alsopreferably includes a medical term matcher responsive to the key wordrecognizer for matching recognized key medical terms used by the atleast one medical personnel with patient conditions and/or treatments tothereby add additional data thereto.

[0012] The present invention also advantageously provides a medicalrecord having a selected format. The medical record preferably includesa plurality of primary key medical terms responsively generated by thevoice of at least one medical personnel and arranged in the selectedformat. The primary key medical terms are preferably generated by thefree, unprompted, and unstructured dictation of the at least one medicalpersonnel and preferably include at least patient conditions andtreatments. The medical record also includes additional secondary textresponsively generated by the presence of the primary key medical termsand arranged in the selected format. The additional secondary textpreferably at least includes medical terms describing patient conditionsand/or treatments related to the plurality of primary key medical termsdescribing patient conditions and/or treatments but not being a subsetof the plurality of primary key medical terms.

[0013] The present invention yet further provides methods of forming amedical record. A method of forming medical records preferably includesgenerating a plurality of key medical terms, recognizing the pluralityof key medical terms responsive to a key medical term database having aplurality of key medical terms stored therein, matching recognized keymedical terms used by the at least one medical personnel with knownpatient conditions and treatments stored in a knowledge database whichrelates patient conditions with patient treatments of the conditions sothat the knowledge base assists in further describing at least theactual condition and/or treatment of the patient by adding additionaldata thereto, and creating an actual patient medical record responsiveto the matched recognized key medical terms.

[0014] Another method of forming medical records according to thepresent invention preferably includes inputting unprompted andunstructured free dictation of at least one medical personnel,processing the inputted voice to thereby generate voice data therefrom,recognizing key medical terms freely dictated by the at least onemedical personnel responsive to a key medical term database having aplurality of key medical terms stored therein, matching recognized keymedical terms used by the at least one medical personnel with knownpatient conditions and/or treatments to thereby add additional datathereto, and creating an actual patient medical record therefrom.

[0015] Yet another method of forming medical records according to thepresent invention preferably includes inputting dictation of at leastone medical personnel, processing the recorded voice to thereby generatevoice data therefrom, recognizing key medical terms dictated by the atleast one medical personnel responsive to a key medical term databasehaving a plurality of key medical terms stored therein, and matchingrecognized key medical terms used by the at least one medical personnelwith known patient conditions and/or treatments to thereby addadditional data thereto.

[0016] By providing a knowledge database, or other knowledge storagemedium which at least includes patient conditions and/or also preferablypatient treatments or potential treatments related to a correspondingpatient condition, the present invention advantageously provides anapparatus and method of forming a medical record which adds additionaltext which are also preferably related to the same patient conditionsand/or treatments to the existing medical terms to provide a morecomplete record or a record according to either a selected orpredetermined format to thereby further describe additional data orinformation desired to be in a medical record. This feature, forexample, can advantageously allow a physician or other medical personnelto dictate as desired and yet have some assurance that the first draftof the medical record will be fairly complete. The physician, forexample, can then revise the medical record. By reference to the sameknowledge database for checking on the impact of the revised oradditional terms provided by the physician with the terms added from theknowledge database, the apparatus can then provide a revised medicalrecord. Such revisions advantageously can be repeated until the medicalrecord is acceptable to the physician.

BRIEF DESCRIPTION OF THE DRAWINGS

[0017] Some of the features, advantages, and benefits of the presentinvention having been stated, others will become apparent as thedescription proceeds when taken in conjunction with the accompanyingdrawings in which:

[0018]FIG. 1 is an environmental view of a physician freely dictating toa medical record forming and storing apparatus according to the presentinvention;

[0019]FIG. 2 is a block diagram of a medical record forming and storingapparatus according to the present invention;

[0020]FIG. 3 is a block diagram of the operations of a medical recordforming and storing apparatus according to the present invention; and

[0021]FIG. 4 is a schematic view of a medical record such as created orformed from a patient encounter and having primary key medical terms andsecondary text according to the present invention.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS

[0022] The present invention will now be described more fullyhereinafter with reference to the accompanying drawings, in whichpreferred embodiments of the invention are shown. This invention may,however, be embodied in many different forms and should not be construedas limited to the illustrated embodiments set forth herein. Rather,these illustrated embodiments are provided so that this disclosure willbe thorough and complete, and will fully convey the scope of theinvention to those skilled in the art. Like numbers refer to likeelements throughout, and prime and double prime notation, if used,indicate similar elements in alternative embodiments.

[0023] FIGS. 1-2 illustrate an apparatus 10 for forming and storingmedical records 15 (see, e.g., FIG. 4) according to the presentinvention which preferably uses a combination of hardware elements andsoftware programs and/or databases for forming the apparatus. Themedical record forming and storing apparatus 10 preferably includesvoice inputting means, e.g., preferably provided by a voice recorder 12,for inputting the unprompted and unstructured free dictation of at leastone medical personnel such as a physician, and voice processing means,e.g., preferably provided by a voice processor or voice data processor20 such as one or more microprocessors, microcontrollers, digitalprocessing devices or circuits, software processors, computer voicerecognition software, or other data processors as understood by thoseskilled in the art, responsive to the voice inputting means 12 forprocessing the freely dictated voice from the voice inputting means 12and generating voice data therefrom. As understood by those skilled inthe art, the voice recorder 12, for example, can be any of various typesof audio tape, digital media recorders, direct dictation into a softwareprogram, or other voice input devices such as produced by companies suchas Dictaphone, Lanier, Pitney Bowes, IBM, Microsoft, Dragon Systems, orKurzwell Applied Intelligence. The voice processor 20 preferablyincludes at least one microprocessor having stored commands forprocessing data and/or other hardware and software as understood bythose skilled in the art.

[0024] As set forth herein, the term free dictation means theunstructured and unprompted dictation of the at least one medicalpersonnel. By unstructured and unprompted, it is recognized that words,sentences, and paragraphs have structure which often prompts additionalstructure such as a limited set of predetermined answers to a promptedquestion. Nevertheless, this is not the intent of the meaning ofunstructured and unprompted. Rather, medical personnel such asphysicians are allowed to dictate words, terms, sentences, phrases,paragraphs, and other language structure without the necessity of usingonly selected words, terms, phrases, paragraphs, and other structurerequired by the system or apparatus 10 into which the physician or othermedical personnel dictates or speaks. In other words, the dictation doesnot have to be within a given format required by the medical recordingforming system or apparatus 10 outside of normal language usage by thespeaking of the medical personnel and is preferably not based upon alimited set of predetermined answers to a prompted question.

[0025] By advantageously using or keying off of key medical terms usedby a physician P or other medical personnel such as in free, unprompted,and unstructured dictation, the apparatus 10 and method of the presentinvention provide freedom to the physician P to talk, speak, and dictateaccording to the physician's personal preferences, style, language,vocabulary, tone, and other desires when forming a medical record.Non-key medical terms or other unrecognized words, for example, canadvantageously be discarded or stored for future reference. Thephysician P, for example, does not have to fit within the constraints orformat requirements of the system or apparatus 10 which receives thedictation and forms the medical record therefrom. Because the freedictation is the preferred format and key medical terms are recognizedby the apparatus 10, additional personnel to transcribe the physician'sdictation are not needed.

[0026] The voice processing means 20 also can advantageously includespeech term learning means, e.g., a speech learner 24 such as formed insoftware and/or hardware as understood by those skilled in the art, forlearning speech terms used by identified medical personnel and/or speechpattern learning means, e.g., a pattern learner 26 such as formed insoftware and/or hardware as understood by those skilled in the art, forlearning speech patterns used by identified medical personnel. Toperform these functions, for example, the apparatus 10 can also includebiometric identifying means 27 connected to the voice processing means20 for identifying biometric data from medical personnel to therebyreference previous terms or patterns from previous dictations to theapparatus by the identified medical personnel. As understood by thoseskilled in the art, the biometric identifying means is preferably avoice identification pattern, tone, or other voice identifier 27. Otherbiometric identifiers, however, such as fingerprint characteristics, eyecharacteristics, skin characteristics, body fluid characteristics, orother user characteristics can be used as well according to the presentinvention.

[0027] The apparatus 10 preferably also has key term recognizing means,e.g., preferably provided by a key term recognizer 30, responsive to thevoice processor 20 for recognizing key medical terms freely dictated bythe at least one medical personnel. The key term recognizing means 30,for example, can include key medical term storing means, such as a keymedical term database 35, for storing a plurality of key medical terms,comparing means, e.g., a comparator 32, responsive to the key medicalterm storing means for comparing the voice data with key medical termswithin the key medical term storing means, and separating means, e.g., amedical term separator 33 such as provided by a natural language parseras understood by those skilled in the art, responsive to the comparingmeans for separating the key medical terms from the non-key medicalterms. The key term recognizing means 30 can also advantageously includenon-key term eliminating means, e.g., a non-key term eliminator 36, foreliminating non-key terms from the generated voice data. The key termrecognizing means 30 can additionally include non-key term storingmeans, e.g., a memory slot 1, responsive to the non-key term eliminatingmeans 36 for storing the eliminated non-key terms for future reference.

[0028] The apparatus 10 also preferably includes medical term matchingmeans, e.g., preferably provided by a medical term matcher formed insoftware or a predetermined stored commands, responsive to the key termrecognizing means 30 for matching medical terms used by the at least onemedical personnel at least with patient conditions, and also withtreatments as well. The medical term matching means 50 preferablyincludes a knowledge database 55 relating patient conditions withadditional condition data, words, terms, and, if desired, even patienttreatments of the conditions so that the knowledge base assists infurther describing at least the actual condition and/or treatment of thepatient by adding additional data to a medical record 15 which is orwill be created. The matching preferably includes a comparator softwaresubroutine or other matching routine as understood by those skilled inthe art. The comparator preferably systematically compares the medicalterm with other data or terms related thereto or exactly matching in adatabase.

[0029] By providing a knowledge database 55, or other knowledge storagemedium which at least includes patient conditions and/or also preferablypatient treatments or potential treatments related to a correspondingpatient condition, the apparatus 10 advantageously can add additionalmedical terms also preferably related to the same patient conditionsand/or treatments to the existing medical terms to more completelydescribe at least the patient condition and thereby provide a morecomplete record or a record 15 according to either a selected orpredetermined format to thereby further describe additional data orinformation desired to be in a medical record 15. As understood by thoseskilled in the art, the knowledge database 55 preferably has astructured tree configuration which enables each recognized key medicalterm, as well as sets or combinations of recognized key medical terms,to be searched for related medical terms such as patient conditions,diagnosis, and/or treatments. Such structural tree configurations arewell known in the art and include nodes, branches, and leafs related toa root node such as illustrated in FIG. 2, which can relate the primarykey medical terms dictated by the physician P to other secondary termsor text which should be included with the medical record which alsorelate to patient conditions, treatments, symptoms, or other desireddata to also be added to the medical record 15 (see also FIG. 4).

[0030] This feature, for example, can advantageously allow a physician Por other medical personnel to dictate as desired and yet have someassurance that the first draft of the medical record 15 will be fairlycomplete. The physician P, for example, can then revise the medicalrecord 15. By reference to the same knowledge database 55 for checkingon the impact of the revised or additional terms provided by thephysician P with the terms added from the knowledge database 55, theapparatus can then provide a revised medical record 15. Such revisionscan be repeated until the medical record 15 is acceptable to thephysician P.

[0031] Accordingly, the apparatus 10 can further include medical recordcreating means, e.g., preferably provided by a medical record creator70, responsive to the medical term matching means 50 for creating anactual patient medical record 15 therefrom and medical record storingmeans, e.g., a memory slot 2, responsive to the medical record creatingmeans 70 for storing an accepted medical record 15 created therefrom forfuture reference. The medical record creating means 70, for example, canadvantageously include draft record generating means, e.g., illustratedby the notes 74 for generating a draft medical record related to the atleast one medical personnel's dictation for review by the at least onemedical personnel, record revising means, e.g., a revisor 75, responsiveto the at least one medical personnel for revising the draft medicalrecord, and record accepting means, e.g., an acceptor 78, responsive tothe at least one medical personnel for accepting the draft medicalrecord 15. The apparatus 10 can also include a medical personnel userinterface 95 responsive to the medical record creating means forproviding a user interface to medical personnel so that draft medicalrecords can readily be revised. The user interface 95 is preferablyprovided by a display terminal, keyboard, mouse, and/or a printer forproviding a means for revising the draft record or notes 15 (see FIGS. 1and 4). The record revising means 75 preferably includes knowledgedatabase revised term matching means, e.g., preferably provided by abest-fit matching software program 76 as understood by those skilled inthe art, responsive to the knowledge database 55 for matching termsrevised by the at least one medical personnel from the user interface 95with terms in the knowledge database 55. The knowledge database revisedterm matching means 76 includes best-fit comparing means for comparingthe revised term with terms within the knowledge database 55 based upona best-fit matching configuration.

[0032] As perhaps best illustrated in FIG. 4, the present invention alsoadvantageously provides a medical record 15 having a selected formatsuch as produced from a patient encounter by a physician or othermedical personnel. The medical record 15 preferably is a progress noteor narrative description of a patient encounter and preferably includesa plurality of primary key medical terms 16 responsively generated bythe voice of at least one medical personnel and arranged in the selectedformat. The primary key medical terms 16 are preferably generated by thefree, unprompted, and unstructured dictation of the at least one medicalpersonal and preferably include at least patient conditions andtreatments. The medical record 15 also includes additional secondarytext 18 responsively generated by the presence of the primary keymedical terms 16, positioned interspersed with and adjacent each of theplurality of primary key medical terms, and arranged in the selectedformat. The additional secondary text 18 preferably is readable data,words, or other information and can include medical terms describingpatient conditions and/or treatments related to the plurality of primarykey medical terms 16 describing patient conditions and treatments butnot being a subset of the plurality of primary key medical terms 16. Themedical record 15 also can advantageously include at least oneacceptance identifier 19 associated therewith for identifying that themedical record has been accepted by the at least one medical personnelwhose voice generated the plurality of primary medical terms 16.

[0033] As illustrated in FIGS. 1-4, the present invention yet furtherprovides methods of forming a medical record 15. A method of formingmedical records 15 preferably includes generating a plurality of keymedical terms 16, recognizing the plurality of key medical terms 16responsive to a key medical term database 35 having a plurality of keymedical terms stored therein, matching recognized key medical terms usedby the at least one medical personnel with known patient conditions andtreatments stored in a knowledge database 55 which relates patientconditions with patient treatments of the conditions so that theknowledge base 55 assists in further describing at least the actualcondition and/or treatment of the patient by adding additional datathereto, e.g., more completely describing at least a condition and/ortreatment, and creating an actual patient medical record responsive tothe matched recognized key medical terms.

[0034] This method can also advantageously include storing a createdmedical record 15 accepted by at least one medical personnel for futurereference. The recognizing step preferably includes eliminating non-keyterms from generated data and storing the eliminated non-key terms forfuture reference. The creating step preferably includes generating adraft medical record related to the at least one medical personnel'sdictation for review by the at least one medical personnel, revising thedraft medical record responsive to the at least one medical personnel,and accepting the draft medical record. The revising step preferablyincludes providing a knowledge database revised term matcher 76responsive to the knowledge database 55 for matching terms revised bythe at least one medical personnel with terms in the knowledge database55. The knowledge database revised term matcher 76 can advantageouslyinclude a best-fit comparator for comparing the revised term with termswithin the knowledge database based upon a best-fit matchingconfiguration. A user interface 95 to medical personnel can also beprovided so that the draft medical records 15 can readily be revised.

[0035] Another method of forming medical records 15 according to thepresent invention, as perhaps best illustrated by the operationalprocess 100 in FIG. 3, preferably includes inputting, e.g., receiveand/or record, unprompted and unstructured free dictation of at leastone medical personnel (Block 101), processing the inputted voice tothereby generate voice data therefrom (Block 102), recognizing keymedical terms 16 freely dictated by the at least one medical personnelresponsive to a key medical term database 35 having a plurality of keymedical terms stored therein (Blocks 104-106), matching recognized keymedical terms 16 used by the at least one medical personnel with knownpatient conditions and treatments to thereby add additional data thereto(Block 107), and creating an actual patient medical record 16 therefrom(Blocks 108-110).

[0036] The method can further include storing a created actual medicalrecord 15 accepted by the at least one medical personnel for futurereference (Block 111). The matching step preferably includes providing aknowledge database 55 having a structured tree configuration whichrelates patient conditions with patient treatments of the conditions sothat the knowledge base 55 assists in further describing the actualcondition of the patient by adding additional data thereto (Block 107).Also, the processing step can include learning speech terms used byidentified medical personnel and/or learning speech patterns used byidentified medical personnel (Block 103). The method can further includeidentifying biometric data from medical personnel to thereby referenceprevious terms or patterns from previous dictations by the identifiedmedical personnel.

[0037] Further still, the recognizing step preferably includeseliminating non-key terms from the generated voice data (Block 106) andstoring the eliminated non-key terms for future reference. The creatingstep can include generating a draft medical record related to the atleast one medical personnel's dictation for review by the at least onemedical personnel (Block 109), revising the draft medical record 15responsive to the at least one medical personnel (Block 110), e.g., byfurther dictation such as indicated by the solid arrowed line aboveBlock 104, by typing, using one or more fonts, softkeys, icons, orclicking on or selecting word, symbol, or phrase choices displayed on adisplay or screen and/or audibly heard as indicated by the brokenarrowed lines above Blocks 107 and 108, and accepting the draft medicalrecord (Block 109). The revising step preferably includes providing aknowledge database revised term matcher 76 responsive to the knowledgedatabase 55 for matching terms revised by the at least one medicalpersonnel with terms in the knowledge database 15. The knowledgedatabase revised term matcher 76 preferably includes a best-fitcomparator for comparing the revised term with terms within theknowledge 55 database based upon a best-fit matching configuration. Auser interface to medical personnel is also preferably provided so thatthe draft medical records 15 can be revised therefrom.

[0038] Yet another method of forming medical records 15 according to thepresent invention preferably includes receiving dictation of at leastone medical personnel, processing the received voice to thereby generatevoice data therefrom, recognizing key medical terms dictated by the atleast one medical personnel responsive to a key medical term database 35having a plurality of key medical terms 16 stored therein, and matchingrecognized key medical terms used by the at least one medical personnelwith known patient conditions and treatments to thereby add additionaldata, such as additional medical terms thereto.

[0039] This method can also include creating an actual patient medicalrecord 15 responsive to the matched recognized key medical terms andstoring a created medical record 15 accepted by the at least one medicalpersonnel for future reference. The matching step can preferably includeproviding a knowledge database 55 having a structured tree configurationwhich relates patient conditions with patient treatments of theconditions so that the knowledge database 55 assists in furtherdescribing the actual condition of the patient by adding additional datathereto. Also, the processing step can include learning speech termsused by identified medical personnel and/or learning speech patternsused by identified medical personnel.

[0040] The method can further include identifying biometric data frommedical personnel to thereby reference previous terms or patterns fromprevious dictations by the identified medical personnel. The recognizingstep preferably includes eliminating non-key terms from the generatedvoice data and storing the eliminated non-key terms for futurereference. The creating step can include generating a draft medicalrecord 15 related to the at least one medical personnel's dictation forreview by the at least one medical personnel, revising the draft medicalrecord 15 responsive to the at least one medical personnel, andaccepting the draft medical record 15. The revising step preferablyincludes providing a knowledge database revised term matcher 75responsive to the knowledge database 55 for matching terms revised bythe at least one medical personnel with terms in the knowledge database55. The knowledge database revised term matcher 76 preferably includes abest-fit comparator for comparing the revised term with terms within theknowledge database 55 based upon a best-fit matching configuration. Auser interface 95 to medical personnel is also preferably provided sothat the draft medical records 15 can be revised therefrom.

[0041] Many modifications and other embodiments of the invention willcome to the mind of one skilled in the art having the benefit of theteachings presented in the foregoing descriptions and the associateddrawings. Therefore, it is to be understood that the invention is not tobe limited to the specific embodiments disclosed, and that modificationsand embodiments are intended to be included within the scope of theappended claims.

That which is claimed is:
 1. A medical record processor comprising: avoice processor for receiving unprompted and unstructured free dictationfrom medical personnel, for processing the dictation, and for generatingvoice data comprising a plurality of terms therefrom; a key termcomparator for identifying a key medical term in the generated voicedata by comparing each term in the generated voice data with a pluralityof key medical terms; a separator for separating the identified keymedical terms from non-key medical terms in the generated voice data andfor eliminating a non-key medical term from the generated voice data; amedical term matcher for matching the identified key medical term with apatient condition and for extracting from a knowledge databaseadditional data on the patient condition; and a medical record creatorfor generating a draft medical record comprising the identified keymedical term and the additional data.
 2. The medical record processorrecited in claim 1, further comprising a personnel identifier foridentifying the medical personnel from whose dictation the generatedvoice data have come.
 3. The medical record processor recited in claim2, wherein the personnel identifier comprises a biometric identifierselected from a group consisting of a voice identifier, a fingerprintidentifier, an eye characteristic identifier, a skin characteristicidentifier, and a body fluid identifier.
 4. The medical record processorrecited in claim 2, wherein the voice processor comprises at least oneof a speech learner and a pattern learner having access to at least oneset of stored voice data from the identified medical personnel.
 5. Themedical record processor recited in claim 1, wherein the key termcomparator comprises means for accessing a database containing theplurality of key medical terms.
 6. The medical record processor recitedin claim 1, wherein the separator comprises a natural language parser.7. The medical record processor recited in claim 1, further comprisingsoftware means for routing the eliminated non-key medical term to amemory device for storing the eliminated non-key medical term therein.8. The medical record processor recited in claim 1, wherein theadditional data from the knowledge database comprise treatment datarelated to the patient condition.
 9. The medical record processorrecited in claim 1, wherein the comparator comprises a softwaresubroutine.
 10. The medical record processor recited in claim 1, whereinthe knowledge database has a structured tree configuration for relatingthe patient condition to related data including at least one of atreatment, a symptom, and a diagnosis.
 11. The medical record processorrecited in claim 1, further comprising a revisor in electroniccommunication with a user interface for receiving and implementing auser revision to the draft medical record to create an accepted medicalrecord.
 12. The medical record processor recited in claim 11, whereinthe user interface comprises at least one of a display terminal, akeyboard, a pointing device, and a printer.
 13. The medical recordprocessor recited in claim 12, wherein the revisor comprises means formatching the user revision with data in the knowledge database.
 14. Themedical record processor recited in claim 13, wherein the matching meanscomprises a best-fit comparing software routine.
 15. The medical recordprocessor recited in claim 11, further comprising a medical recordstorage routine for storing the accepted medical record.
 16. The medicalrecord processor recited in claim 15, further comprising means foradding an acceptance identifier to the accepted medical record.
 17. Themedical record processor recited in claim 1, further comprising amedical record storage routine for storing the draft medical record. 18.A medical record processing system comprising: a voice input device; avoice processor for receiving unprompted and unstructured free dictationfrom a medical personnel via the voice input device, for processing thedictation, and for generating voice data comprising a plurality of termstherefrom; a key term comparator for identifying a key medical term inthe generated voice data by comparing each term in the generated voicedata with a plurality of key medical terms; a separator for separatingthe identified key medical terms from non-key medical terms in thegenerated voice data and for eliminating a non-key medical term from thegenerated voice data; a medical term matcher for matching the identifiedkey medical term with a patient condition and for extracting from aknowledge database additional data on the patient condition; and amedical record creator for generating a draft medical record comprisingthe identified key medical term and the additional data.
 19. The systemrecited in claim 18, wherein the voice input device comprises a voicerecorder.
 20. The system recited in claim 18, further comprising apersonnel identifier for identifying the medical personnel from whosedictation the generated voice data have come.
 21. The system recited inclaim 18, further comprising a key medical term database containing theplurality of key medical terms, and wherein the key term comparatorcomprises means for accessing the key medical term database.
 22. Thesystem recited in claim 18, wherein the separator comprises a naturallanguage parser.
 23. The system recited in claim 18, further comprisinga memory device for storing the eliminated non-key medical term andsoftware means for routing the eliminated non-key medical term thereto.24. The system recited in claim 18, further comprising a storage devicewhereon the knowledge database resides.
 25. The system recited in claim24, wherein the additional data from the knowledge database comprisetreatment data related to the patient condition.
 26. The system recitedin claim 24, wherein the comparator comprises a software subroutinehaving means for accessing the storage device.
 27. The system recited inclaim 24, wherein the knowledge database has a structured treeconfiguration for relating the patient condition to related dataincluding at least one of a treatment, a symptom, and a diagnosis. 28.The system recited in claim 18, further comprising a user interface anda revisor in electronic communication with the user interface forreceiving and implementing a user revision to the draft medical recordto create an accepted medical record.
 29. The system recited in claim28, wherein the user interface comprises at least one of a displayterminal, a keyboard, a pointing device, and a printer.
 30. The systemrecited in claim 28, wherein the revisor comprises means for matchingthe user revision with data in the knowledge database.
 31. The systemrecited in claim 30, wherein the matching means comprises a best-itcomparing software routine.
 32. The system recited in claim 28, furthercomprising a storage device and a medical record storage routine forstoring the accepted medical record on the storage device.
 33. Thesystem recited in claim 32, further comprising means for adding anacceptance identifier to the accepted medical record.
 34. The systemrecited in claim 18, further comprising a storage device and a medicalrecord storage routine for storing the draft medical record on thestorage device.
 35. A method for processing an orally delivered medicalrecord comprising the steps of: receiving unprompted and unstructuredfree dictation from medical personnel; processing the dictation andgenerating voice data comprising a plurality of terms from the processeddictation; identifying a key medical term in the generated voice data bycomparing each term in the generated voice data with a plurality of keymedical terms; separating the identified key medical terms from non-keymedical terms in the generated voice data and eliminating a non-keymedical term from the generated voice data; matching the identified keymedical term with a patient condition and extracting from a knowledgedatabase additional data on the patient condition; and generating adraft medical record comprising the identified key medical term and theadditional data.
 36. The medical record processing method recited inclaim 35, further comprising the step of identifying the medicalpersonnel from whose dictation the generated voice data have come. 37.The medical record processing method recited in claim 35, wherein thepersonnel identifying step comprises the step of performing a biometricidentification.
 38. The medical record processing method recited inclaim 35, wherein the processing step comprises the step of using atleast one of a speech learner and a pattern learner having access to atleast one set of stored voice data from the identified medicalpersonnel.
 39. The medical record processing method recited in claim 35,wherein the identifying step comprises accessing a database containingthe plurality of key medical terms.
 40. The medical record processingmethod recited in claim 35, wherein the separating step comprises performing natural language parsing.
 41. The medical record processingmethod recited in claim 35, further comprising the step of storing theeliminated non-key medical term in a memory device.
 42. The medicalrecord processing method recited in claim 35, wherein the additionaldata from the knowledge database comprise treatment data related to thepatient condition.
 43. The medical record processing method recited inclaim 35, wherein the extracting step comprises the step of relating thepatient condition to related medical data including at least one of atreatment, a symptom, and a diagnosis.
 44. The medical record processingmethod recited in claim 35, further comprising the steps of receivingand implementing a user revision to the draft medical record to createan accepted medical record.
 45. The medical record processing methodrecited in claim 44, wherein the implementing step comprises the step ofmatching the user revision with data in the knowledge database.
 46. Themedical record processing method recited in claim 45, wherein thematching step comprises the step of performing a best-fit comparison.47. The medical record processing method recited in claim 45, furthercomprising the step of storing the accepted medical record.
 48. Themedical record processing method recited in claim 47, further comprisingthe step of adding an acceptance identifier to the accepted medicalrecord.
 49. The medical record processing method recited in claim 35,further comprising the step of storing the draft medical record.
 50. Amedical record processing method comprising the steps of: inputtingunprompted and unstructured free dictation from a medical personnel intoa voice input device; receiving the dictation from the voice inputdevice; processing the dictation and generating voice data comprising aplurality of terms therefrom; identifying a key medical term in thegenerated voice data by comparing each term in the generated voice datawith a plurality of key medical terms; separating the identified keymedical terms from non-key medical terms in the generated voice data andeliminating a non-key medical term from the generated voice data;matching the identified key medical term with a patient condition andextracting from a knowledge database additional data on the patientcondition; and generating a draft medical record comprising theidentified key medical term and the additional data.
 51. The medicalrecord processing method recited in claim 50, further comprising thestep of identifying the medical personnel from whose dictation thegenerated voice data have come.
 52. The medical record processing methodrecited in claim 50, further comprising the step of accessing a keymedical term database containing the plurality of key medical terms. 53.The medical record processing method recited in claim 50, wherein theseparating step comprises the step of performing natural languageparsing.
 54. The medical record processing method recited in claim 50,further comprising the step of storing the eliminated non-key medicalterm in a memory device.
 55. The medical record processing methodrecited in claim 50, wherein the extracting step comprises the step ofaccessing a storage device whereon the knowledge database resides. 56.The medical record processing method recited in claim 55, wherein theadditional data from the knowledge database comprise treatment datarelated to the patient condition.
 57. The medical record processingmethod recited in claim 50, wherein the knowledge database has astructured tree configuration for relating the patient condition torelated data including at least one of a treatment, a symptom, and adiagnosis.
 58. The medical record processing method recited in claim 50,further comprising the steps of receiving and implementing a userrevision to the draft medical record to create an accepted medicalrecord.
 59. The medical record processing method recited in claim 58,wherein the implementing step comprises the step of matching the userrevision with data in the knowledge database.
 60. The medical recordprocessing method recited in claim 59, wherein the matching stepcomprises the step of performing a best-fit comparison.
 61. The medicalrecord processing method recited in claim 50, further comprising thestep of storing the accepted medical record.
 62. The medical recordprocessing method recited in claim 61, further comprising the step ofadding an acceptance identifier to the accepted medical record.
 63. Themedical record processing method recited in claim 50, further comprisingthe step of storing the draft medical record.